Read Maternity Care Coordination text version

Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May 1, 2007

Table of Contents

1.0 2.0 Description of the Service................................................................................................................1 Eligible Recipients ...........................................................................................................................1 2.1 General Provisions..............................................................................................................1 2.2 Limitations ..........................................................................................................................1 2.3 EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age ..................................................................................................................1 When the Service Is Covered...........................................................................................................2 When the Service Is Not Covered....................................................................................................3 Requirements for and Limitations on Coverage ..............................................................................3 5.1 Enrollment ..........................................................................................................................3 5.2 Initial Assessment ...............................................................................................................3 5.3 Plan of Care ........................................................................................................................5 5.4 Subsequent Contacts ...........................................................................................................5 5.5 Home Visits ........................................................................................................................6 5.6 Transfer...............................................................................................................................6 5.7 Discontinuation...................................................................................................................7 5.8 Transition ............................................................................................................................7 5.9 Closure ................................................................................................................................7 5.10 Evaluation and Reporting ...................................................................................................8 Providers Eligible to Bill for the Service .........................................................................................8 6.1 Provider Enrollment............................................................................................................8 6.1.1 Provider Application..............................................................................................8 6.1.2 Approval ................................................................................................................8 6.1.3 Termination............................................................................................................9 6.2 Staffing Qualifications........................................................................................................9 6.3 Staffing Requirements ........................................................................................................9 Additional Requirements .................................................................................................................9 Billing Guidelines ..........................................................................................................................10 8.1 Claim Type .......................................................................................................................11 8.2 Diagnosis Codes That Support Medical Necessity ...........................................................11 8.3 Procedure Code(s).............................................................................................................11 8.4 Reimbursement Rate.........................................................................................................11 Policy Implementation/Revision Information................................................................................11

3.0 4.0 5.0

6.0

7.0 8.0

9.0

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May 1, 2007

1.0

Description of the Service

The maternity care coordination program provides formal case management services to eligible women during and after pregnancy and intervention as early in pregnancy as possible to promote healthy pregnancy and positive birth outcomes. Maternity care coordination services must be provided by a qualified care coordinator. The process consists of successful completion of the following activities: a. Outreach: Assist potentially eligible clients in applying for Medicaid, develop a strong referral network, and increase community awareness of expanded Medicaid coverage and benefits. b. Recruitment: Encourage clients to enroll in the maternity care coordination program. This includes evaluating Medicaid status, explaining maternity care coordination services, and obtaining the client's consent. c. Assessment: Determine client's strengths and needs, including psychosocial, nutritional, medical, educational, and financial factors. d. Service Planning: Develop an individualized description of what services and resources are needed to meet the needs of the client and provide assistance in accessing those resources. e. Coordination and Referral: Assist the client in arranging for appropriate services, ensure that appropriate services are received and that there is continuity of care. f. Follow-up and Monitoring: Assess ongoing progress and ensure that services are delivered. g. Education and Counseling: Educate and inform the client in preparation for childbirth and parenting. Guide the client and develop a supportive relationship that promotes the plan of care.

2.0

Eligible Recipients

2.1 General Provisions

Medicaid recipients may have service restrictions due to their eligibility category that would make them ineligible for this service.

2.2

Limitations

Pregnant and postpartum women who receive Medicaid are eligible for this service. Note: Postpartum is defined as the period of time from the last day of pregnancy through the last day of the month in which the 60th post-delivery day occurs.

2.3

EPSDT Special Provision: Exception to Policy Limitations for Recipients under 21 Years of Age

Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) is a federal Medicaid requirement that requires the state Medicaid agency to cover services, products, or procedures for Medicaid recipients under 21 years of age if the service is medically necessary health care to correct or ameliorate a defect, physical or mental illness, or a condition [health problem] identified through a screening examination** (includes any

CPT codes, descriptors, and other data only are copyright 2006 American Medical Association. All rights reserved. Applicable FARS/DFARS apply. 04102007 1

Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

evaluation by a physician or other licensed clinician). This means EPSDT covers most of the medical or remedial care a child needs to improve or maintain his/her health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. Medically necessary services will be provided in the most economic mode, as long as the treatment made available is similarly efficacious to the service requested by the recipient's physician, therapist, or other licensed practitioner; the determination process does not delay the delivery of the needed service; and the determination does not limit the recipient's right to a free choice of providers. EPSDT does not require the state Medicaid agency to provide any service, product, or procedure a. that is unsafe, ineffective, or experimental/investigational. b. that is not medical in nature or not generally recognized as an accepted method of medical practice or treatment. Service limitations on scope, amount, duration, frequency, location of service, and/or other specific criteria described in clinical coverage policies may be exceeded or may not apply as long as the provider's documentation shows that the requested service is medically necessary "to correct or ameliorate a defect, physical or mental illness, or a condition" [health problem]; that is, provider documentation shows how the service, product, or procedure will correct or improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. **EPSDT and Prior Approval Requirements a. If the service, product, or procedure requires prior approval, the fact that the recipient is under 21 years of age does NOT eliminate the requirement for prior approval. b. IMPORTANT ADDITIONAL INFORMATION about EPSDT and prior approval is found in the Basic Medicaid Billing Guide, sections 2 and 6, and on the EPSDT provider page. The Web addresses are specified below. Basic Medicaid Billing Guide: http://www.ncdhhs.gov/dma/medbillcaguide.htm EPSDT provider page: http://www.ncdhhs.gov/dma/EPSDTprovider.htm

3.0

When the Service Is Covered

IMPORTANT NOTE: EPSDT allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service, product, or procedure will correct or improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED. For additional information about EPSDT and prior approval requirements, see Section 2.0 of this policy.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

Maternity care coordination services are covered during pregnancy and through the end of the month in which the 60th postpartum day occurs. Maternity care coordination services are covered for women who experience a spontaneous abortion (miscarriage), a therapeutic elective abortion, fetal demise or molar pregnancy through the end of the month in which the 60th postpartum day occurs.

4.0

When the Service Is Not Covered

IMPORTANT NOTE: EPSDT allows a recipient less than 21 years of age to receive services in excess of the limitations or restrictions below and without meeting the specific criteria in this section when such services are medically necessary health care services to correct or ameliorate a defect, physical or mental illness, or a condition [health problem]; that is, documentation shows how the service, product, or procedure will correct or improve or maintain the recipient's health in the best condition possible, compensate for a health problem, prevent it from worsening, or prevent the development of additional health problems. EPSDT DOES NOT ELIMINATE THE REQUIREMENT FOR PRIOR APPROVAL IF PRIOR APPROVAL IS REQUIRED. For additional information about EPSDT and prior approval requirements, see Section 2.0 of this policy. Maternity care coordination services are not covered when the criteria listed above are not met.

5.0

Requirements for and Limitations on Coverage

Maternity care coordination services include assessment, development, implementation, and evaluation of the plan of care for pregnant and postpartum women.

5.1

Enrollment

Enrollment in the maternity care coordination program must be a one-on-one, face-toface encounter. Explanation of the services and that the service is voluntary are part of the enrollment process. Enrollment in the maternity care coordination program should be in the client's county of residence. Clients receiving prenatal care in the private sector are also eligible to participate in the maternity care coordination program. A pregnant or postpartum woman is enrolled in the maternity care coordination program when she has signed the Letter of Agreement (DMA-3004 Rev. 10/99) or the approved equivalent indicating her desire to participate in the program and designating her maternity care coordinator. The Letter of Agreement may also indicate a secondary maternity care coordinator to assist in care coordination in the absence of the primary maternity care coordinator. Immediately following enrollment in the maternity care coordination program, the maternity care coordinator must complete the Family Strengths/Needs Assessment (DMA 3006 Rev. 5/00) or the approved equivalent.

5.2

Initial Assessment

The goals of the initial assessment are to establish rapport with both the client and care providers; to provide assistance in meeting the service objectives; and to establish a schedule for follow-up assessments that addresses the service objectives and meets

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

minimum program requirements for frequency of client contact. A maternity care coordinator must complete the initial assessment. The components of the initial maternity care coordination assessment are as follows. a. Determine the current status of Medicaid eligibility. b. Explain maternity care coordination services to the client. 1. Help the client locate providers and services. 2. Assist the client in planning visits to providers and arranging for transportation when needed. 3. Develop a plan of care with input from the client and the medical prenatal care provider to help ensure the best possible pregnancy outcome based on the client's needs. 4. Assist in the completion of forms and paperwork as required for other programs. 5. Work with the providers, especially prenatal care providers, to make sure the plan of care is followed and revised if necessary. 6. Listen to the client's needs and concerns and integrate them into the plan of care. 7. Help the client plan for the continuing health care of her child(ren). 8. Provide information about other services available within the community for the client's use. c. Explain maternity support services to the client. 1. coverage of pregnancy-related medical services 2. transportation 3. prescriptions 4. childbirth and parenting classes 5. dental care 6. maternal care skilled nurse home visit 7. health and behavior intervention 8. medical nutritional therapy 9. newborn Medicaid coverage 10. home visit for postnatal assessment and follow-up care 11. home visit for newborn care and assessment Note: Enrollment in the maternity care coordination program is not necessary in order to benefit from maternity support services. d. Explain the client's responsibilities while receiving maternity care coordination services. 1. Select a primary care provider and give the name of the maternity care coordinator. 2. Agree to work with the maternity care coordinator to develop a plan of care based on the client's identified needs. 3. Agree to follow the plan of care as developed by the client, maternity care coordinator, and the prenatal care provider. e. Obtain the client's signature on the Letter of Agreement.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

f. g. h.

Complete the Family Strengths/Needs Assessment form. Refer the client to the Women, Infants, and Children (WIC) Special Supplemental Nutrition program. Provide client/prenatal education. 1. Counsel the client about the importance of early and continuous prenatal care. 2. Assist the client in finding a prenatal care provider, if necessary. 3. Ensure that the client has received health education materials. 4. Provide information on childbirth or parenting classes available in the agency or community. 5. Provide information on tobacco usage, second-hand smoke, and smoking cessation programs. 6. Provide information on substance/alcohol usage during pregnancy and assist with locating support groups/treatment. 7. Advise against the use of any drugs/medications during pregnancy unless prescribed by a prenatal care provider. 8. Encourage the client to adhere to the prenatal care provider's plan of care. 9. Encourage and develop a plan for labor and delivery, which includes a support person and transportation. 10. Assist in obtaining an infant safety seat and advise the client on the infant safety law and seat usage. Note: The maternity care coordinator has a legal obligation to report situations of clear and imminent danger to the appropriate authority.

5.3

Plan of Care

The purpose of the plan of care is to document the work being done by both the family and the maternity care coordinator. Agencies with Maternal Outreach Worker programs must also document Maternal Outreach Worker duties on the plan of care. Key points in the development of the plan of care include a. the agreement between the client and the maternity care coordinator on areas to be addressed, including priorities identified by the client; b. care coordination goals and activities written in clear, behavioral terms indicating specific responsibilities and timelines for accomplishment and reassessment; c. strengths identified as resources; and d. modification according to changes in identified needs.

5.4

Subsequent Contacts

Maternity care coordination subsequent contacts must be one-on-one, face-to-face visits conducted in the clinic, home, or a convenient site. The subsequent contact may also be an exchange of information by telephone or letter. Although frequency and duration of services are to be determined by the needs of the client, a minimum monthly contact is required. The maternity care coordinator is responsible for ensuring that mandated follow-up of missed appointments occurs.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

Subsequent contacts should be individualized and include the following: a. Number and complexity of problems b. Availability of caregivers within the area c. Availability of services within the area d. Client's and her family's ability to meet their own needs and use available support systems During the subsequent contact, the maternity care coordinator must a. Review the Family Strengths/Needs Assessment for new concerns or changes in the status of previously identified concerns b. Reassess the priorities of the client c. Assess and reassess the family/client relationships d. Update and revise the plan of care as needed e. Make necessary referrals and follow-up on previous referrals f. Discuss the future plans and/or transitions to other programs or services

5.5

Home Visits

Maternity care coordination home visits must be one-on-one, face-to-face visits conducted in the client's home. A home visit is determined to be necessary when it is needed to implement the developed plan of care or to prevent the client from discontinuing services. Home visits are considered subsequent contacts and meet the minimum monthly contact requirement. In addition to the requirements outlined in subsequent contacts, the home visit must also include one or more of the following: a. Assessment of the home environment b. Monitoring of the client's adherence to their plan of care c. Education/counseling d. Referral and follow-up e. Other support services, as needed

5.6

Transfer

The client may elect to obtain maternity care coordination services from another provider. In this case, the transferring maternity care coordinator must coordinate activities by a. obtaining a signed medical release of information; b. updating the plan of care; c. notifying appropriate caregivers of status change; d. initiating contact with the new maternity care coordinator by letter/telephone to review the client's file and share significant information; e. discussing transfer of services with the client and assisting with information regarding the new provider; and f. transferring a copy of the care coordination record(s), including all required forms. A new Letter of Agreement must be signed by the new maternity care coordinator and the client once the transfer is complete.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

5.7

Discontinuation

Maternity care coordination services may be discontinued only for the following reason(s): a. Services are terminated at the end of the month in which the 60th postpartum day occurs b. Client transfers out of the county c. Client states she no longer wishes to receive services d. Client is lost to follow-up after repeated attempts to locate her e. Client expires during the eligibility period f. Client is no longer eligible for Medicaid

5.8

Transition

The maternity care coordinator must provide follow-up services to the mother and infant when transitioning the family to the child service coordination program. The transition must include the following. a. Follow-up services for the mother: 1. Assist in locating a medical provider for her ongoing health needs. 2. Refer and assist in obtaining appropriate family planning services. 3. Provide and assist with information on community resources. 4. Provide and assist with information on parenting and well child care. 5. Refer and arrange for postpartum WIC certification. 6. Notify the client and caregivers that maternity care coordination services are being discontinued. 7. Ensure that the Pregnancy Outcome Summary/Report has been completed correctly and has been submitted. b. Follow-up services for the infant: 1. Ensure that the local department of social services has been notified of the infant's birth and that the newborn has received Medicaid certification. 2. Assist in locating a medical provider for ongoing well child and sick care. 3. Ensure that the mother has the Health Check program brochure and understands that preventive services are available for children under the age of 21. 4. Consult with the local Health Check program coordinator regarding medical appointments for the infant and arranging medical transportation. 5. Refer and arrange for WIC certification for the infant. 6. Inform and assist the mother on the use of infant/child safety seats. 7. Coordinate the transition of care coordination services with the Child Service Coordinator.

5.9

Closure

Maternity care coordination services must be closed when one of the discontinuation provisions specified in Section 5.7, Discontinuation, occurs. The maternity care coordinator must

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

a. b. c. d.

provide and assist with information on community resources; update the plan of care to reflect the final maternity care coordination service status; notify the client and caregivers that maternity care coordination services have terminated; and document reason for termination.

When maternity care coordination services are discontinued at the client's request, the maternity care coordinator should a. consider transferring the case to another maternity care coordinator or b. follow up after termination to determine if the client would like to re-enroll.

5.10

Evaluation and Reporting

In order to collect data necessary for measuring the effectiveness of maternity care coordination services, maternity care coordinators are responsible for completing a Pregnancy Outcome Summary/Report for each client upon the completion of care coordination services. The Pregnancy Outcome Summary/Report must be submitted within 30 days of discontinuation of services. Local health departments must complete the Pregnancy Outcome Summary (DEHNR 3080). This data must be submitted through the Health Services Information System (HSIS). All other maternity care coordination provider agencies (i.e., Federally Qualified Health Centers, Rural Health Clinics, physicians) must complete the Pregnancy Outcome Report (DMA-3002 Rev. 9/99). This report is submitted to Baby Love Program Division of Medical Assistance 2501 Mail Service Center Raleigh NC 27699-2501

6.0

Providers Eligible to Bill for the Service

Community and migrant health centers, Federally Qualified Health Centers, local health departments, private practitioners, regional perinatal providers, and Rural Health Clinics are eligible to provide this service. The caseload size for a full-time maternity care coordinator is 100 clients per year or 60 to 70 clients at any given time.

6.1

Provider Enrollment 6.1.1 Provider Application

A signed provider application (DMA-3008) must be on file for each agency that provides maternity care coordination services.

6.1.2

Approval

The Division of Public Health and the Division of Medical Assistance must approve the application.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

6.1.3

Termination

Provider participation may be terminated in accordance with provisions contained within the agreement.

6.2

Staffing Qualifications

This service must be rendered by a. a registered nurse (RN) who is licensed in the State of North Carolina and has a minimum of one year of experience in community health nursing and working with pregnant women and families; or b. a social worker with a master's degree in social work, bachelor's degree in social work, or employment as a social worker meeting state Social Worker II qualifications with a minimum of one year of experience in health and human services and working with pregnant women and families; or c. a maternity care coordinator trainee who is either 1. an RN who is licensed in the State of North Carolina; or 2. a social worker with a master's degree in social work, bachelor's degree in social work or employed as a social worker meeting state Social Worker II qualifications. When additional years of experience are needed to meet the required number of years for Social Worker II qualifications, the work experience requirement cannot be waived. The work experience requirement is waived when the trainee is an RN, BSN, BSW, or MSW. The trainee must work under the supervision of an experienced maternity care coordinator. The duties and functions of a trainee are the same as outlined for the maternity care coordinator. This includes carrying a caseload and does not require the signature of the supervising maternity care coordinator. The supervising maternity care coordinator must a. arrange informal weekly conferences with the trainee; b. provide timely access for the trainee; and c. ensure that the supervisor and trainee relationship is defined in the agency policy.

6.3

Staffing Requirements

The maternity care coordinator must be a. employed by a qualified service provider; and b. required to attend state-sponsored "Basic Training" within one year of hire date Note: Student interns cannot provide maternity care coordination services for Medicaid reimbursement.

7.0

Additional Requirements

At a minimum, the client's record must include the following documentation: a. Signed Letter of Agreement b. Completed Family Strengths/Needs Assessment c. Plan of care d. Dates of client contact or attempted contact

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

e. Type of contact (face-to-face, home visit, exchange of information by telephone) f. Actions taken from previous contacts; problems resolved g. Plan of care concerns addressed during the contact and the actions to be taken by the client and the maternity care coordinator before the next contact h. Modifications to the original plan of care i. Next scheduled contact j. Total service time component (example: 35 minutes = 2 units) k. Signature of the maternity care coordinator Documentation of contacts can occur on narrative notes (DMA-3016 Rev. 7/99), care plans (DMA-3007 Rev. 7/93) or Subjective data, Objective data, Assessment, and Plan of Action (SOAP) notes. When applicable, agencies may opt to develop their own equivalent forms. However, components of the local forms must contain all the elements of the state-created forms and must be approved by the regional social work consultant prior to implementation.

8.0

Billing Guidelines

Reimbursement requires compliance with all Medicaid guidelines, including obtaining appropriate referrals for recipients enrolled in the Medicaid managed care programs. Maternity care coordination services are reimbursed up to six units per month. One unit = 15 minutes. Additional units may be requested through the claims adjustment process. Claims for additional units will be considered for reimbursement only when conditions of coverage are met and documentation supports the following medical necessity factors (or high-risk criteria): a. Medical high-risk factors related to pregnancy outcome such as preterm labor, hypertension, pre-eclampsia, diabetes, suspected fetal growth retardation, multiple pregnancy, renal disease, HIV infection/AIDS, perinatal substance abuse, and/or other high-risk medical conditions b. Substance abuse (alcohol or drugs) or history of substance abuse with potential negative impact on current pregnancy c. Child abuse or family violence with potential negative impact on current pregnancy d. Mental impairment/retardation Maternity care coordination must be billed per date of service. Maternity care coordination services cannot be reimbursed when provided on the same date as the following services: a. Child service coordination b. Home visit for newborn care and assessment c. Home visit for postnatal assessment and follow-up care d. Maternal care skilled nurse home visit e. Maternal outreach worker services If a Health and Behavior Intervention home visit is determined to be necessary during a maternity care coordination home visit, bill only one service.

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Division of Medical Assistance Maternity Care Coordination

Clinical Coverage Policy No.: 1M-8 Original Effective Date: October 1, 2002 Revised Date: May1, 2007

8.1 8.2

Claim Type

CMS-1500 (HCFA-1500)

Diagnosis Codes That Support Medical Necessity

V22.0 Supervision of normal first pregnancy V22.1 Supervision of other normal pregnancy V22.2 Pregnant state, incidental V23.0 Pregnancy with history of infertility V23.1 Pregnancy with history of trophoblastic disease V23.2 Pregnancy with history of abortion V23.3 Grand multiparity V23.4 Pregnancy with other poor obstetric history V23.5 Pregnancy with other poor reproductive history V23.7 Insufficient prenatal care V23.81 Elderly primigravida V23.82 Elderly multigravida V23.83 Young primigravida V23.84 Young multigravida V23.89 Other high-risk pregnancy V23.9 Unspecified high-risk pregnancy V24.0 Immediately after delivery V24.2 Routine postpartum follow up

8.3 8.4

Procedure Code(s)

HCPCS code T1017--Targeted case management, each 15 minutes

Reimbursement Rate

Providers must bill their usual and customary charges.

9.0

Policy Implementation/Revision Information

Original Effective Date: October 1, 2002 Revision Information: Date 9/1/05 9/1/05 12/1/05 12/1/06 5/1/07 Section Revised Section 2.0 Section 8.0 Section 2.3 Sections 2 through 4 Sections 2 through 4 Change A special provision related to EPSDT was added. Text stating that providers must comply with Medicaid guidelines was added to Section 8.0. The web address for DMA's EDPST policy instructions was added to this section. A special provision related to EPSDT was added. EPSDT information was revised to clarify exceptions to policy limitations for recipients under 21 years of age.

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